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Preventing Diabetic Blindness
Rajvithi Hospital
Thailand

The Problem

Diabetic Blindness:
Diabetes is a chronic lifelong disease. Diabetic retinopathy (DR) is the most common ocular complication of diabetes, and is the leading cause of new blindness among adults aged 20 to 74 worldwide. Approximately 40-60% of patients with diabetes have DR. The World Health Organization estimated that DR was responsible for 4.8% of the 38 million blind people worldwide. In developing countries, this blindness affects people in the middle, productive years, aged between 35 and 64. Extensive research has proved that timely detection and treatment can reduce the rate of blindness significantly from 50% to 5%. Screening for DR has also been proven to be cost-effective. A universal guideline suggests that patients with diabetes should have an eye examination at least once a year.

A huge number of patients with diabetes, especially those who live in rural areas, do not have the recommended eye examination. Even patients in the United States had only a 50% rate of eye examination. Furthermore, less than 40% of those who have high-risk characteristics of blindness received treatment. Many eyes with these characteristics may still have normal vision. Ophthalmologists therefore cannot wait until patients develop poor vision to treat.

Thailand's Situation:
In Thailand, more than 3 million people have diabetes but only about 100,000 of them have the recommended eye examination. There are only approximately 1,000 ophthalmologists nationwide, including 100 retina specialists to deliver eye care. Half of them practice in Bangkok, whereas the majority of the patients, who do not have the examination, live in rural areas about 100 kilometers away from provincial hospitals where ophthalmologists practice.

Based on the National Survey of Blindness, conducted in 2006-2007, 34% of diabetic patients in the survey were found to have low vision or blindness in either eye. Furthermore, DR is the most common retina disease that causes bilateral low vision.

A Struggling Model:
Tak is a province located 400 kilometers west of Bangkok, next to Myanmar. There was only one ophthalmologist working in a public provincial hospital. The ophthalmologist had realized his inability to provide routine eye care to patients in his rural area. He therefore spent his weekends carrying an ophthalmoscope to various communities to examine patients with diabetes to detect DR. Despite his hard work and dedication, in 2006, he could achieve only 20% coverage of eye examinations of the 4,618 diabetic patients in his province.

The Center of Excellence in Retina Diseases in Rajavithi Hospital, Bangkok, is a public tertiary care center that takes care of referred retina cases from most of provincial hospitals in Thailand. We operated on severe, advance DR with retinal detachment for more than 200 cases a year. Only half of these cases could have visual improvement after the surgery.

This conservative model cannot be applied to prevent blindness from diabetes.

Solution and Key Benefits

 What is the initiative about? (the solution)
We implemented the first pilot project for preventing blindness from DR in rural areas of Tak province in 2007.

We co-operated with provincial health care officers in Tak for setting up a local community health care team in rural areas to assist the ophthalmologist. Personnel in the team were recruited from volunteered health care officers in community hospitals who were local people, and might not necessarily be physicians. We trained them to interpret digital retinal images to identify patients with diabetes who were at risk of blindness and refer them to the ophthalmologist. They were also supervised to run this project themselves.

Solutions on the perspective of rural patients:
In the first year, more than 2,600 patients accessed this project, which was 60.7% of the diabetic patients in Tak. In the second year, this coverage improved, to more than 90%. The number of high-risk eyes detected improved from 15.3% in 2007, 30.2% in 2008, to 40.6% in 2009. A total of 1,620 eyes had laser treatments at Tak Provincial Hospital and 920 had improved or stable vision. Seven eyes were referred to have surgery at Rajavithi Hospital in Bangkok and five had visual improvement.

After this achievement, we extended our project into four more provinces. They were 463-828 kilometers from Bangkok. There were 81,056 patients with diabetes in the four provinces. A total of 58,510 (72.2%) of them were screened for DR. 7,392 (12.6%) of these patients were referred due to DR, an additional 2,679 (4.6%) patients were also referred due to other eye diseases. There were 2,228 (3.8%) patients who were treated by ophthalmologists in the provinces, whereas 163 (0.3%) patients were referred to be treated by retina specialists in regional tertiary care hospitals. There were 2,922/58,510 (5%) patients found to have blindness in the first year. This decreased to be 3.7% in the second year.

Solutions on the perspective of rural personnel:
We trained 425 nurses or technicians from the four provinces to be primary DR screeners. Their qualification in identifying eyes with high-risk for blindness (referrals), using identification by a retina specialist as standard, was assessed in terms of sensitivity (correctly identify referral cases) and specificity (correctly identify non-referral cases). The qualification level was set for each screener to have at least 85% of sensitivity and 85% of specificity.

Before training, the trainees had an average sensitivity of 71.4% (range 50-82.5%) and specificity of 0.55% (range 35.8-80%) with only 6.5% (range 3.1-10%) of the trainees had both sensitivity and specificity more than 85%. After training, the average sensitivity improved to 92% (range 90.1-94.3%) and the average specificity improved to 80% (range 71.5-89.8%). The proportion of the trainees who had both sensitivity and specificity more than 85% was 46.8% (range 26.9-79.1%).

Rural people, both patients with diabetes and the trained personnel in the community teams, benefited the most; provincial ophthalmologists, regional retina specialists, and policy makers are also benefited from this initiative.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
The Center of Excellence in Retina Diseases, Rajavithi Hospital (COE) and the Institute of Medical Research and Technology Assessment (IMRTA), both in the Department of Medical Services, Ministry of Public Health, proposed this initiative.

We work in the COE, which is a center of medical excellence that has commitments in pursuing excellence in being a tertiary care center, research center, reference center, establishing a regional referral center, proper technology transfer, medical network, and advocacy in national policy.

We chose to solve a problem of DR because it was the leading cause of blindness from retina diseases and the most common eye disease referred to our hospital. It is still the most common eye disease referred in the past three years (1,777/3,335 [53.3%] in 2009, 3,453/5,692 [60.7%] in 2010, 6,880/10,305 [66.8%] in 2011). Furthermore, this initiative could fit well into all the seven areas of excellence we committed to pursue.

The IMRTA has collaborated closely with us in assessing the use of digital retinal images for DR management. We organized skill transfer courses for establishing local community DR Management teams in rural areas. We developed the course curriculum, recruited volunteers, and conducted the teaching together. This initiative fit perfectly with the priority policy of the Department of Medical Services of the Ministry of Public Health in tackling problems of chronic non-communicable diseases, such as diabetes.

The local community DR Management team implements this initiative in their community. The team, the diabetic patients in their area, the COE, and the IMRTA are the major stakeholders. The followings are other stakeholders.

Other Government Bodies:
The Office of the Permanent Secretary of the Ministry of Public Health (OMPH), the command body for all provincial and community hospitals in Thailand, supports the roles of personnel in the hospitals to form the DR Management team with us.

The National Health Security Office (NHSO), a government agency responsible for health care payments in Universal Coverage insurance scheme in Thailand, has endorsed this initiative. NHSO has played an important role in providing budget for retinal image interpretations, and treatment when this initiative is implemented at a national level.

Profession Organizations:
We co-operated with the Thai Retina Society (TRS), in which attending staff from our COE are currently Chair and committee members, to organize a group discussion for retina specialists in Thailand to set up a guideline for DR management. There was a consensus from the meeting that health care personnel that were not physicians could be trained to assist ophthalmologists to prevent blindness from diabetes.

The Royal College of Ophthalmologists of Thailand (RCOPT) endorsed the guideline. We published it in the Thai Journal of Ophthalmology, and were invited to present it in the annual academic meeting of the RCOPT. The TRS and RCOPT have still provided academic support for this initiative.

Public Sector:
Village health volunteers work closely with the local DR management team in registration of patients with diabetes into this initiative. They also take care of the patients on the screening days.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The main objective of this initiative is to prevent blindness from diabetes.

We have divided this initiative into three phases.

The Pre-Screening Phase:
This is conducted by the Central DR Management Board, which consists of personnel in the COE, and the IMRTA. The divisions in the Board are the Administrative unit, Academic unit, Secretariat unit, and ICT unit.

Strategies used:
1) Converting tacit knowledge into explicit knowledge
2) Promoting evidence-based decision-making
3) Improving human resources’ skills and productivity

Activities:
1) Conducting research on digital retinal images by the Academic unit of the DR Board
2) Creating Guidelines for DR Management by the Academic unit in collaboration with TRS, distributing the guidelines by the Academic and the Secretariat units in collaboration with RCOPT.
3) Mapping resources of all provinces in Thailand to select appropriate provinces to implement at the beginning. This was conducted by the Administrative and the Secretariat units and the OMPH.
4) Website and ICT tools creation by the ICT unit
5) Preparing the selected local communities by the Secretariat unit in collaboration with village health volunteers and the local DR Management team
6) Organizing training courses by the Academic and the Secretariat units in collaboration with the local DR Management team

The Screening Phase:
This phase is conducted by the trained local community DR Management team in their community.

Strategies used:
1) Applying modern equipment, e.g. digital retinal camera
2) Applying ICT tools
3) Transforming passive service culture into active service culture


Activities:
1) Capturing retinal images
2) Interpreting the retinal images
3) Measuring visual acuity and intraocular pressure
4) Giving health education
5) Collecting and managing data

The Post-Screening Phase:
Both the Central DR Management Board and local community DR Management team conducted this phase.

Strategies used:
1) Applying ICT tools
2) Creating learning community

Activities:
1) Data management, consultation, and referrals conducted via telemedicine by local community DR Management team
2) Data confirmation, monitoring, feedback by provincial ophthalmologists and regional retina specialists via telemedicine.
3) Treatment of referred patients by ophthalmologists, retina specialists
4) Higher policy makers and the DR Board access the data for monitoring
5) Organizing a meeting among the DR Board, the local community DR Management teams, ophthalmologists, and retina specialists to obtain feedback from the discussion group.

Road Map and Challenges for the Future:
Extend this initiative to cover most provinces of Thailand. Receive more involvement from other possible stakeholders, such as public media to promote this initiative. Since diabetes can cause complications in other organs, such as the heart, kidneys, and feet, involvement of other groups of physicians, e.g. cardiologists, nephrologists, and orthopedists, to screen those complications at the same time is challenging.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
We applied a Knowledge Management Process Framework to develop and implement this initiative.

Knowledge Acquisition:
The standard for diagnosis of DR severity has been established since the 1980s. This is an interpretation of stereo photographs of the retina captured in seven specific areas. This standard is not accepted in the real world due to complex acquisition and interpretation. In the early 1990s, Polaroid images were introduced but it was not useful due to poor image quality. The screening for DR changed dramatically in early 2000s, when digital retinal images were introduced.

We assessed this technology for real-time, remote, image interpretation and published the results in Journal of Medical Association of Thailand in 2005. We then assessed an agreement in interpretation of the images by different health care personnel and published the results in the journal of the American Academy of Ophthalmology in 2006. We found a potential that health care personnel who were not physicians could be trained to detect referrals with 80-90% sensitivity and 70-80% specificity. We presented another study evaluating capability of trained ophthalmic nurses for screening DR at the American Academy of Ophthalmology annual meeting in 2008. We used this evidence for implementing DR screening in the real world.

Evidence-based knowledge acquisition is the key development step.

Knowledge Sharing and Transferring:
In 2008, we co-operated with IMRTA to establish a skills transfer course and workshop for DR management. The two-day course was initially conducted for classroom training, it then evolved into hybrid training, which included both classroom and web-based training. The curriculum in the classroom course includes 1) lectures on diabetes, pathophysiology of DR, pathological lesions of DR and 2) practice of retinal image capturing and reading. The trainees were then required to interpret images from real patients in a web-based e-learning system. There were 400 images to be used for practice.

Knowledge Networking:
In 2010, we added telemedicine technology, such as consultation, referral, and a database system into the website to connect local community teams, ophthalmologists, retina specialists, and policy makers into the same network. Mobile technology was used to notify consultants in the network once there was a new case submitted for consultation or referral.

In 2011, we developed software for zipping data and images from screening in communities, to be transmitted via the Internet. The data was then automatically unzipped, stored and displayed on our website. This is used for monitoring coverage of retinal images captured at the rural screening sites. A self-test practice system for the trained local community personnel to continue monitoring their own sensitivity and specificity of interpretation competency was also established on the website.

Integrating ICT into this initiative is the key implementing step.

Knowledge is Dynamic: Paradigm Shift of DR Treatment:
In a few years ahead, based on strong evidence in recent research, we look forward to changing treatment of DR from laser to injecting medications into the indicated eyes. This may allow us to treat more patients, with lower cost, and more visual improvement.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
Obstacles on Knowledge Transferring:
Problems with defining the severity level for referrals:
There were five severity levels of DR based on the International Clinical Classification. Initially, we trained the screeners to classify all five levels with a severity level of 4 or higher set as referrals; however, sensitivity and specificity for identifying this was only 50-60%. The definition of referrals was then changed to be a level of 3 or higher. This has improved overall sensitivity and specificity to be more than 80%. This was used as a guideline. A community screening team may change to refer a level of 2 or higher; this depended on resources and the policy of ophthalmologists and provincial health officers in the province. Referring cases at a lower severity level may give more sensitivity with more cases referred, and possibly more false positives but less false negatives.

Quality of the primary screeners:
We explored many cutoff points and found that 85% sensitivity and 85% specificity can be achievable in each of the trained screeners. This qualification is also high enough to implement in the real world. Continuing education with an e-learning system to refresh theory and practice was created to keep this qualification.

Obstacles on Knowledge Networking:
Problems related to telemedicine application:
We applied real-time modality for transmitting images to be read at a central reading center in the initial phase. We found this impractical, based on results from our published study and from implementation. We then applied a store-and-forward modality by saving images on CDs for ophthalmologists to interpret later. This created too much workload for them (There are only 2-3 ophthalmologists in a province to read more than 10,000 images of patients in their province). Therefore, we currently adopt a system of real-time image interpretation by trained local community screeners at screening sites, with a store-and-forward system for ophthalmologists to confirm the readings by the screeners via a website.

The problem of different brands of retinal cameras:
Since we collected data of local community screenings at a central server, we therefore wrote customized software to allow the screeners to zip all data and images screened in a day to be transmitted into the server with ease. The different brands of the camera had different ways of storing data and images; therefore, we needed to write different software for different cameras.

Obstacles on Implementation:
Chronic disease management scheme:
The screening for DR is a long-term task. It needs re-scheduling for screening in the following year for each patient. Sustainability of this project is therefore very important. This is a unique character of chronic diseases, which is different from other eye diseases, such as cataracts that require a single surgery to cure the disease. This is the main reason why we focused on training local personnel for the sustainability of this initiative in rural areas.

Flooding of patients referred when the initiative was first implemented:
Provincial government resources, and national resources provided by the NHSO, are prepared to tackle these problems.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
Most of the financial resources were used in the Screening Phase. A major investment in this phase is the cost of a digital retinal camera, which is about 30,000 USD. This can be supported by the yearly provincial health care budget and is a one-off investment with few maintenance costs. In Surin province, the eleven community hospitals shared the cost of the camera together and used it with rotation. Some provinces adopt this model. Currently, 66/77 (85.7%) provinces of Thailand have digital retinal cameras.

Other costs on screening days were for human resources. There were four personnel needed on the screening days: a visual acuity and intraocular pressure measurer, an image capturer and reader, a health educator, and a data manager. These are personnel required in the local community DR Management team.

For the Pre-Screening Phase, the majority of the cost was for the classroom-based skills transfer course. It cost 3,000 USD when it was set in Bangkok, where the travel and accommodation expenses of trainees were accounted for. It was cheaper by half when it was held in other provinces. Another cost was for creating and maintaining the website which was a core for integrating ICT tools of this initiative.

Human resources used for the Pre- and Post-Screening Phase are personnel in our Central DR Management Board. We combined personnel from two institutions of the Department of Medical Services, Ministry of Public Health into this Board: personnel from the COE Retina, Rajavithi Hospital, and personnel from the IMRTA.

A retina specialist from the COE, who is also the Assistant Director for Management of COE of Rajavithi Hospital, and the Director of the IMRTA oversee the whole project together. Other personnel are two programmers in the ICT unit, a research assistant in the Academic unit, two data managers and two collaborators in the Administrative unit, and a secretariat. The average salary of government officers in this initiative is 500 USD a month.

The economic costs of patients with advanced DR are tremendous. These include direct medical costs for both diabetes itself and DR including other related eye diseases, indirect medical costs for patients who go blind and need social assistance, and intangible costs for patients in the working age group who go blind and therefore lose productivity.

All these costs exist no matter whether this initiative is implemented or not, because we have to treat patients with diabetes and DR on regular basis. These direct costs should increase if this initiative was initially implemented nationwide with more high-risk eyes detected. The NHSO has already reserved budget for this purpose, especially budget for overtime work of screeners and ophthalmologists. However, we can offset all these costs with much lower investment in this initiative in the long run.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
Strategies for Sustainability:
Enhance Good Governance:
Village health volunteers are the key persons who connect our teams of government officers with patients in communities. They are local people who volunteer to take care of health issues in their community. Each volunteer is responsible for ten households in each community. There are currently 13,195 village health volunteers in Thailand.
Collaboration between the Central DR Management Board and profession organizations, such as TRS and RCOPT makes this initiative sustainable.
Customized management plan in each province based on their resources also makes this initiative sustainable.

Enhance Screeners' Competency and Motivation:
We collected training resources, such as PowerPoint slides, standard retinal images, guidelines within the website with easy retrievals. A web-based interactive practice was built for ease of use.
We are working with the Nursing Council on giving continuing education credits to the trained DR screening nurses. This screening task should be built into a routine job with a job description embedded into the local personnel in the future.

Motivation of individual screeners is improved by listing the names of those who had the highest reading scores or achieved the qualification on the home web page. The running of this initiative by local team themselves is social motivation. The local personnel are proud with their competency on preventing their own patients from going blind. Setting group discussions among the local community teams to get feedback created functional motivation.

Based on our survey, 102/113 (90.3%) of the responded personnel will keep doing the screening after the first implemented year.


Replication at National and International level:
Since the pilot project in Tak and four more provinces, DR management project has been conducted in 38/77 (50%) provinces. There are trained community personnel in 66/77 (86.8%) provinces with digital retinal cameras available in 66/77 (85.7%) provinces. More projects in more provinces have being organized. We are supervising these projects and monitoring quality of the trained screeners.

We have joined with the TRS and the RCOPT to organize lectures, symposiums, and instruction courses in the annual academic meeting of the Royal College since 2006. This has inspired many provincial ophthalmologists to develop their own project. Some invited us to set up a model in their province. Some customized their own models, based on our findings and results.

We have been invited to present this project in many international meetings, such as the Asia-Pacific Academy of Ophthalmology, the Asia-Pacific Vitreo-retina Society and the Asia-Association of Research in Vision and Ophthalmology meeting. From discussions in the symposiums we learnt that some countries are in the process of developing their own projects. Some are very interested in following our model. This could lead to the replication of this initiative in those countries. We have a plan to initiate and host an International forum on DR Management in Thailand in the future.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
Lessons Learned About Human Resources:
One of the most important elements that made this initiative success was giving an opportunity to local community health care personnel in rural areas, who were not trained in ophthalmology at all, to solve a problem in public health ophthalmology for their own people. They run their own project and they can do it successfully.

What we did was only a supervision role. We developed frameworks and created tools. We acquired the core knowledge for DR management, shared, and transferred to improve competency of the personnel. We connected them with consultants, mentors, policy makers, and other trained personnel in different provinces. We let them be a part of a knowledge network.

Our knowledge network is not only a virtual social network on the web. It is the real network. The Central DR Management Board organizes a group discussion among personnel on every level of this initiative twice a year. We invite them to share experiences, obstacles, and their success stories. This has made our network becoming a learning community.

Lessons Learned About Technology:
Digital retinal cameras had been commercially available in Thailand for a few years before we set up the pilot project in Tak province. Nothing occurred for DR management during the time. There was no any DR screening programs in Thailand. Patients in rural areas still could not access eye care.

Once we implemented the use of the cameras in the real world, many things started to change. More and more DR screening programs came up in more and more provinces.

This has given us an impression that having technology alone, without proper management, is not the final answer to solve problems.

When we developed the skills transfer course, we looked into a web-based only teaching course. We found it did not improve the trainees’ competency on retinal image reading. Only 6/33 (18.2%) trainees had both sensitivity and specificity more than 85% after the training, compared to 46.8% trainees who had the same qualification after hybrid training.

This has also given us an impression that the most productivity does not come with technology itself, it comes with proper use of technology by humans and human interaction.

Lessons Learned About Human Resources, Technology, and Knowledge Management
Another important element that made this initiative success is the use of evidence-based decision making. We conducted a series of research projects to prove the competency of rural health care personnel before implementation.

Knowledge is created by humans. Evidence found by humans was accumulated over years and years to form knowledge. Without proper management, knowledge could sit quietly without any useful productivity.

We are lucky enough today that we have technology to manage knowledge effectively. Applying knowledge management can be successful by proper management of human resources and technology. This could eventually lead to a great positive change in our society, such as preventing diabetic patients from blindness.

Contact Information

Institution Name:   Rajvithi Hospital
Institution Type:   Government Agency  
Contact Person:   Dr. Paisan Ruamviboonsuk
Title:   Assistant Director, Rajavithi Hospital  
Telephone/ Fax:   +(66)2-982-9435
Institution's / Project's Website:  
E-mail:   paisan.trs@gmail.com  
Address:   Rajavithi Hospital
Postal Code:   10400
City:  
State/Province:   Bangkok
Country:   Thailand

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